Basic Information
| Provider Information | |||||||||
| NPI: | 1255636585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRICE | ||||||||
| FirstName: | SHERWIN | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2441 CABEZON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
| FaxNumber: | 5057171473 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 ENCINO PL NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722573 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 0164601 | NM | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | CCMH0184991 | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | CCMH0184991 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | NM | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 56353081 | 05 | NM | MEDICAID |